Predictors of In-Hospital Mortality after Decompressive Hemicraniectomy for Malignant Ischemic Stroke.

OBJECTIVE: The purpose of this retrospective multicenter, pooled-data analysis was to determine the factors associated with in-hospital mortality in decompressive hemicraniectomy (DHC) for malignant middle cerebral artery (MMCA) stroke. PATIENTS AND METHODS: The authors reviewed pooled DHC database from 3 countries for patients with MMCA with hospital mortality in spite of DHC to identify factors that predicted in-hospital mortality after DHC. The identified factors were applied to the group of patients who were selected for DHC but either refused surgery and died or stabilized and did not undergo DHC. FINDINGS: There were 137 patients who underwent DHC. Multiple logistic regression analysis showed middle cerebral artery (MCA) with additional infarcts (odds ratio [OR], 7.9: 95% confidence interval [CI], 2.4-26; P = .001), preoperative midline shift of septum pellucidum of 1 cm or more (OR, 3.83: 95% CI, 1.13-12.96; P = .031), and patients who remained unconscious on day 7 postoperatively (8.82: 95% CI; OR, 1.08-71.9; P = .042) were significant independent predictors for in-hospital mortality. The identified factors were applied to the group of MMCA patients not operated (n = 19 refused, n = 47 stabilized) single (P < .001), and two predictive factors (P < .001) were significantly more common in patients who died. Whereas two predicative factors were identified in only 9%-18.2% of survivors, the presence of all three predictive factors was seen only in patients who expired (P < .001). The Hosmer-Lemeshow goodness-of-fit statistics (chi-square = 4.65; P value = .589) indicate that the model adequately describes the data. CONCLUSION: Direct physical factors, such as MCA with additional territory infarct, extent of midline shift, and postoperative consciousness level, bore a significant relationship to in-hospital mortality in MMCA patients undergoing DHC.

Macrovesicular steatosis in living related liver donors: correlation of biopsy findings with CT liver attenuation index and body mass index.

BACKGROUND: Hepatic steatosis threatens post-transplant graft survival; therefore, pre-operative quantification of steatosis is crucial. Gold standard for evaluation is donor liver biopsy but it is invasive. An alternative non-invasive method is a calculation of CT liver attenuation index. BMI can be an independent factor predicting grade of steatosis but it is necessary to re-define appropriate BMI cut-off points that are specific for Asians. OBJECTIVE: To retrospectively analyze CT LAI and BMI for quantitative assessment of macrovesicular steatosis in living related liver donors, using histological analysis as gold standard. MATERIALS AND METHODS: A radiologist blinded to histological grading calculated mean CT hepatic attenuation in 48 potential living related liver donors. RESULTS: CT-derived LAI correctly predicted steatosis in all except 1 patient. Parametric analysis for CT LAI and BMI showed overall weak positive correlation. No significant association was found between BMI and biopsy findings. CONCLUSION: Liver biopsy remains a gold standard for evaluation of steatosis. CT LAI of ≤0 correlates well with significant hepatic steatosis and biopsy may be avoided in such cases. Biopsy may be reserved for patients with CT LAI between 1 and 5. BMI alone is not a good predictor of hepatic steatosis in our study population.

Eagle syndrome; radiological evaluation and management.

Eagle syndrome is a rare condition where elongated temporal styloid processes, or calcified stylohyoid ligaments, are in conflict with the adjacent anatomical structures giving rise to a complex range of symptoms including otalgia, dysphagia, foreign body sensation in throat, pain along carotid artery distribution and others. Commonly, the syndrome is documented to be unilateral. However, bilateral cases are also reported though rarely. Multislice computed tomography scan with 3D reconstruction can be really helpful in diagnosing the elongated styloid processes and their mass effect on the surrounding adjacent anatomical structures. Scan is also helpful in deciding further management and guides the surgeon on how and from where to approach the surgery. We present here a case of a 37-years-old man with significantly enlarged and thickened bilateral styloid process causing significant characteristic symptoms.

Recurrent meningitis in children.

Recurrent meningitis in children, although rare, results in an increased risk of acute complications and long-term morbidity. We did a retrospective case series to analyze the clinical presentation, predisposing factors, treatment and outcome of children with recurrent meningitis admitted at Shifa International hospital, Islamabad. All children presenting with recurrent meningitis from December 2006 to May 2011 were included in the study. There were a total of 8 children with a mean age of 6 +/- 2.97 years (2-10 years). Majority (87%) were males. There was an average of 4 +/- 4.92 (2-9) episodes of meningitis in each patient. Fever with vomiting was the most common (87%) presenting symptom, followed by seizures (62%) and headache (50%). The underlying etiology was confirmed on CSF analysis, computed tomography scan (CT) and magnetic resonance imaging (MRI). About half of them had history of head trauma. All responded to antibiotics and six needed surgery. On follow up, 2 (25%) children had some neurological impairment.

Tension Pneumoperitoneum: A Rare Presentation Of Megacystis Microcolon Intestinal Hypoperistalsis Syndrome.

Megacystis microcolon intestinal hypoperistalsis syndrome also known as Berdon syndrome is characterized by enlarged urinary bladder, small colon and reduced or absent intestinal peristalsis. We report a case of 4 days old female suffering from MMIHS presenting with tension pneumoperitoneum. To the best of our knowledge, this is the first reported case of MMIHS, having this unusual presentation.

Cerebral Microbleeds in an Acute Ischemic Stroke as a Predictor of Hemorrhagic Transformation.

Background Cerebral microbleeds are small, round hypointensities of <10 mm in diameter, evident on T2* gradient-recall echo (GRE) or susceptibility-weighted (SWI) magnetic resonance imaging (MRI) sequences. Objective In this study, our objective was to determine the number and location of cerebral microbleeds in ischemic stroke and to identify the predictive role of microbleeds for hemorrhagic transformation. Materials and methods This was a retrospective cohort study. Microbleeds were visually rated on SWI scans of patients who presented with an ischemic stroke and had an SWI scan within 24 hours of onset and a computed tomography (CT)/MRI scan during follow up. Microbleeds were graded as Grades I-IV. Results Out of 575 stroke patients, 121 did not have an SWI scan and 336 had no follow-up scan. A total of 118 patients were included for a final analysis (75 males, 43 females) out of which 30 had a hemorrhagic transformation. Most microbleeds were in the parietal region (n=46) with 50% transformation (p-value <0.001). The size and grade of microbleeds had a statistical association with hemorrhagic transformation with p-value 0.001 and p-value <0.001, respectively; 33% of patients with Grade 3 microbleeds aging 55-65 years had transformations. Of the patients, 93.3% with Grade 4 microbleeds had a hemorrhagic transformation. 30% of transformations were detected in the first 24 hours while 30% were detected during the first week. Age, gender, comorbidity, and anticoagulant use had no statistical association of conversion of microbleeds into hemorrhagic transformation. Conclusion Microbleeds detected on an SWI scan is a relevant and accurate predictor of hemorrhagic transformations in acute ischemic infarcts and should be added to MRI stroke protocols.

Triple assessment of breast lump.

OBJECTIVE: To determine the sensitivity, specificity, positive and negative predictive values of triple test (TT) consisting of physical examination (PE), mammography, fine needle aspiration cytology (FNAC) in the evaluation and characterization of palpable breast lump. Secondly, whether this can be employed as an alternative for tru cut/ excisional biopsy. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: This study was conducted in the department of diagnostic imaging, Shifa International Hospital (SIH), Islamabad in collaboration with departments of surgery and pathology from January 2004 to June 2005. PATIENTS AND METHODS: It comprised of 35 consecutive females presenting in the breast clinic with palpable lump. Females below 35 years of age were excluded due to low sensitivity of the mammography in depiction of focal breast lesions resulting from glandular parenchyma. Patients with acute inflammatory signs, fungating masses, pregnant ladies as well as those with cystic lesions, as confirmed by ultrasound, were also excluded from the study. Number, size and recurrent masses did not influence the inclusion criterion. Detailed history and physical examination was carried out as per established protocol. It was followed by mammography and FNAC. All cases underwent excisional biopsy irrespective of the results of the triple test. RESULTS: The patients' age ranged from 35 to 75 years with mean age of 45.97. Amongst these, 19 cases were benign (54.28 %) and 16 cases (45.71 %) were malignant. The triple test (TT) was scored as concordant if the elements had either all malignant or all benign results. The triple test was non-concordant if the elements had neither all malignant nor all benign results. The TT was concordant in 19 cases (54.28 %) i.e all the benign cases detected by the triple test were benign on final biopsy (100 % specificity and NPV), all the malignant lesions detected by TT turned out to be malignant on final biopsy (100 % sensitivity and PPV). Triple test was non-concordant in 16 cases (45.71 %). Triple Test was scored as benign or malignant based upon the combined results of two elements amongst three components. Out of these, 11 cases were malignant and 5 were benign. In 4 cases, the components of the triple test were suspicious i.e. BIRAD IV on mammography and slight atypical cells without frank malignancy on FNAC. In current study, suspicious cases were taken as malignant. These turned out to be malignant at the end signifying 100% PPV. However, among the 12 cases where, at least one of the 3 components of TT was benign, FNAC was most accurate (2 False Negative (FN) and 0 False Positive (FP), followed by mammography (2 FN and 3 FP) and physical examination was least accurate with 3 FN and 4 FP. It is of note that in 2 cases where FNAC gave FN results, the other two components were either suspicious or malignant. In those cases where two variables were malignant, FNAC and mammography were most accurate with no false positive or false negative. It was followed by physical examination and FNAC with 1 false negative and no false positive. CONCLUSION: The study shows that when TT is concordant, final treatment may be ensued without open biopsy. In non-concordant cases, FNAC stands as single most important investigation. However due to its false negative results, other components of triple test need to be employed to enhance its efficacy and diagnostic yield. TT is cost effective, easy to perform and time saving approach, however, it can be applied only in those institutions where excellent imaging facilities as well as services of a cytopathologist are available. Due to small sample size, the results of this study needs further verification by relatively larger scale studies.